A study on the functional outcome of fracture neck of ... · Fracture neck of femur have always been a great challenge to surgeons and still are unsolved fractures. It is often a

~ 318 ~

International Journal of Orthopaedics Sciences 2019; 5(1): 318-323

ISSN: 2395-1958

IJOS 2019; 5(1): 318-323

© 2019 IJOS

www.orthopaper.com

Received: 14-11-2018

Accepted: 18-12-2018

Dr. Abhimanyu Singh

Junior Resident, Department of

Orthopaedics, Sri Devaraj Urs

Medical College, Kolar,

Karnataka, India

Dr. Nagakumar JS

Additional Professor,

Department of Orthopaedics, Sri

Devaraj Urs Medical College,

Kolar, Karnataka, India

Correspondence

Dr. Nagakumar JS

Additional Professor,

Department of Orthopaedics, Sri

Devaraj Urs Medical College,

Kolar, Karnataka, India

A study on the functional outcome of fracture neck of

femur managed with cannulated cancellous screws

Dr. Abhimanyu Singh and Dr. Nagakumar JS

DOI: https://doi.org/10.22271/ortho.2019.v5.i1f.57

Abstract Background: Hip fractures are common, they comprise about 20% of orthopedic trauma. Femoral neck

fractures almost account for 50% of all the fractures around hip. Fracture neck of femur still are unsolved

fractures. It is a fracture of fragility due to osteoporosis in elderly, in younger age group, it results from a

high-energy trauma sustained commonly in a road traffic accident.

Aims and Objective: To study the functional outcome in patients treated with cannulated cancellous

screws for neck of femur fracture.

Materials and Methods: In this prospective study, 30 patients with neck of femur fractures were treated

with cannulated cancellous screws at R.L. Jalappa Hospital, Kolar during a period of September 2016 to

September 2018. Patients with pathological fractures, osteoarthritis of hip and pediatric patients were

excluded from the study. Patients were followed up for a period of 6 months and functionally assessed

using Modified Harris Hip score.

Results: 21 were males & 9 females with mean age of 41.3 years. RTA was cause of injury in most

patients. Mean duration of union was 15 weeks. Most of patients had slight to no pain, most of the

patients could perform their daily activities without any restriction and all patients had good range of

motion without any deformity.

Conclusion: At the end of the study we conclude that cannulated cancellous screws provide adequate

fracture fixation, stability, strength, early mobility and excellent union rate of neck of femur fractures.

Keywords: Fracture neck of femur, cannulated cancellous (cc) screws, osteosynthesis

Introduction

Hip fractures are common, they comprise about 20% of the operative workload of orthopedic

trauma. Femoral neck fractures almost account for 50% of all the fractures around hip.

Lifetime risk of sustaining hip fracture is high and lies within a range of 40% to 50% in

females and 14% to 22% in males. Life expectancy is increasing throughout the world, and the

demographic changes is causing the hip fractures incidence to increase [1].

Fracture neck of femur have always been a great challenge to surgeons and still are unsolved

fractures. It is often a fracture of fragility due to osteoporosis in elderly, though in younger age

group, it usually results from a high-energy trauma sustained commonly in a road traffic

accident [2].

Regardless of age of the patient, or the fracture pattern, the primary goal of management of the

fracture is to bring the patient back to a pre-fracture level of function. The ideal treatment of

intra-capsular fractures of the femur neck is still anatomic reduction followed by stable bone

fixation.

For displaced femoral neck fractures, reduction, compression, and rigid internal fixation is

required if union is to be predictable. As nonunion and osteonecrosis develop frequently after

internal fixation of displaced fractures of femur neck, many surgeons recommend primary

prosthetic replacement as the treatment of choice in elderly ambulatory patients [3, 4].

Internal fixation remains the treatment of choice for these fractures in all age groups, more so

in displaced fractures in the younger patients, where preservation of femoral head is the

priority. However, the optimal timing for surgical fixation of these fractures is still open to

debate. It is advocated that fracture reduction and fixation should be performed as a surgical

emergency in an attempt to restore the precarious blood supply to the femoral head and

~ 319 ~

International Journal of Orthopaedics Sciences prevent complications such as non-union and avascular

necrosis, the incidence of these complications being 10-20%

and 10-30% respectively. Avascular necrosis and non-union

predisposes to future degenerative arthritis of hip joint

involved [5, 6].

The rationale behind the prompt treatment of fracture neck of

femur is “preservation of the blood supply” to the femoral

head, which is key for a good long-term result. The fracture is

considered a vascular injury to the femur head blood supply [7,

8]. The degree of vascular compromise is directly proportional

and correlates with the fracture displacement, which affects

healing of the bone and leads to complications. Hence, intra-

capsular fracture neck of femur is considered an orthopaedic

emergency [1] and needs prompt adequate reduction with rigid

internal fixation which improves the femoral head blood

circulation and prevents the troublesome complications.

Internal fixation with cannulated cancellous (CC) screws after

good reduction is the ideal method of treating femur neck

fractures, as there is less blood loss, shorter operative time

and less duration of hospital stay. Thus parallel screw fixation

at present, considered as the standard with which other

implants have to be compared [1].

Therefore, we conducted this study in our institute to evaluate

functional outcome of patients with neck of femur fracture

treated with cannulated cancellous (CC) screws. We specially

focused on the time lapse from injury to the surgery in

relation to union and occurrence of complications such as

non-union.

Objectives of the Study

To assess the efficacy of cannulated cancellous screws in

osteo-synthesis of femoral neck fractures.

To determine the average time taken for union.

To study the functional outcome of fracture neck of

femur managed with cannulated cancellous (CC) screw

fixation and assessing the results.

Methodology

A prospective study on about 30 consecutive patients

with fracture of femoral neck meeting the inclusion and

the exclusion criteria admitted to RL Jalappa hospital

attached to Sri Devaraj Urs Medical College and research

centre were taken up for the study after obtaining the

informed consent between the period of September 2016

to September 2018.

Inclusion Criteria

Undisplaced (Garden type I and II) neck of femur

fractures in all age groups.

Displaced (Garden type III and IV) fractures in patients

below 65 years of age.

Exclusion Criteria

Osteoarthritis of hip joint

Pathologic fracture

Rheumatoid arthritis

Patients with acetabulum fractures

Ipsilateral shaft of femur fracture

Fracture neck of femur with dislocation.

Method of Collection of Data

It is a prospective study.

Admitted patients were evaluated for fitness, routine pre

anesthetic check-up was done and informed written

consent was taken before surgery.

The fractures were classified according to the

Garden’s classification based on radiological

findings and fixed with 3 cannulated cancellous (cc)

screws in an inverted triangle configuration.

Post Operatively

Check x rays pelvis with both hips AP view and operated

hip lateral view were done. The same radiographs were

taken on subsequent follow-ups.

Blood investigations: haemoglobin

Patients were shifted to high dependency surgical ward

and monitored.

Check X-ray of pelvis and both hip in AP and operated

hip in lateral views were done.

Appropriate analgesics (Inj. Diclofenac or Inj. Tramadol)

were given intramuscularly.

IV antibiotics (Inj. Cefotaxime) was given for 2-3 days.

IV fluids in high dependency ward as appropriate were

given.

Stitches were removed 2 weeks after surgery.

The patients were mobilized with strict non-weight bearing

ambulation post-operatively with the help of a walker. They

were discharged with a strict advice of non-weight bearing

ambulation and to do active quadriceps exercises and were

called for follow up after 4 weeks. On subsequent follow up,

the next date of follow up was given.

Fig 1: Guide-wire position confirmation under c-arm fluoroscopy

Fig 2: Final screw positions under c-arm fluoroscopy

Follow Up

Follow up was done on 4th, 8th, 12th, 16th and 24th weeks.

At all follow ups, symptoms like pain or swelling were

noted and a detailed clinical examination was done, and

looked for tenderness, active range of movements of hip

and limb length discrepancy. Subjective assessment of

functional outcome was done using Modified Harris Hip

Score at each follow up.

~ 320 ~

International Journal of Orthopaedics Sciences X-rays were repeated on 4th, 12th and 24th weeks (ie. 1st,

3rd and 5th follow ups) and were observed for signs of

union (trabecular continuity across fracture site), neck-

shaft angle, screw backing out or breaking of screws.

Patients were advised non-weight bearing ambulation for

first 8 weeks, followed by foot touch down (partial

weight bearing) ambulation from 8th-12th week and full

weight bearing after 12 weeks if radiographs showed

signs of union.

Results Following were the observations made and the available data

were analyzed as follows.

1) Age distribution

In this study, majority of cases, 20 (66%) were in 31-50 years

age group, followed by 5 (17%) each in the age group of 18-

30 and above 50. The youngest patient’s age was 24 years and

eldest was 65 years old. The mean age was 41.3 years

Table 1: Age distribution

Age (in years) 18-30 31-40 41-50 >50

No. of cases 5 10 10 5

Percentage 17 33 33 17

2) Sex distribution

In our study, majority 21(70%) of cases were males, and

females were 9(30%) cases, with Male: Female ratio of 3:1.

Table 2: Sex distribution

Sex No. of cases Percentage

Male 21 70

Female 9 30

3) Side involvement

Right side was involved in 18(60%) cases and left side in

12(40%) cases.

Table 3: Side involvement

Side No. of cases Percentage

Right 18 60

Left 12 40

4) Mode of injury

The most common mode of injury was road traffic accident.

21 cases (70%) out of 30 cases were affected due to road

traffic accident and rest 9 cases (30%) were due to fall.

Table 4: Mode of injury

Mode of injury No. of cases Percentage

Road traffic accident (RTA) 21 70

Fall 9 30

5) Fracture type-Garden’s classification

In our study out of 30 cases, majority were Garden’s type II-

15(50%) cases followed by Type III, 8(26.66%) cases, Type

IV, 8(13.33%) and Type I, 3(10%) cases.

Table 5: Fracture type-Garden’s classification

Garden’s classification No. Of cases Percentage

I 3 10

II 15 50

III 8 26.66

IV 4 13.33

6) Time interval between injury and surgery

In our study, 18(60%) cases were operated within 12 hours of

trauma and 12(40%) cases were operated within 12-48 hours.

Table 6: Time interval between injury and surgery

Time elapsed <12 hours >12 hours

No. of cases 18 12

Percentage 60 40

7) Time taken for union

In our study, the average time taken for union was 15 weeks.

Most of the cases showed union in 12weeks, 17 patients

followed by 16 weeks in 7 patients and 24 weeks, 6 cases.

Table 7: Time taken for union

Union (weeks) Twelve Sixteen Twenty four

No. of cases 17 7 6

8) Complications

In our study, 6(20%) cases had complications. The most

common complication were superficial infection and backing

out of screws, 4 cases (13.33%). There were no implant

failure or non-union.

Table 8: Complications

Complications No. of cases Percentage

Superficial infection 4 13.33

Backing out of screw 4 13.33

Restricted movements 3 10

9) Results-According to Modified Harris Hip score

In the present study, 30 patients with fracture neck of femur

were treated surgically. The results were satisfactory in

93.33% cases by the subjective Modified Harris Hip scoring

system. The functional outcome was Excellent in 22 cases

(73.33%), Good in 6 cases (20%) and in 2 cases (6.66%) Fair.

Excellent results were observed equally irrespective of timing

of surgery in our study i.e within 2 days. No patient had a

poor outcome at their final follow up.

Table 9: Results-According to Modified Harris Hip score

Results No of cases Percentage

Excellent 22 73.33

Good 6 20

Fair 2 6.66

Poor 0 0

Pre op X-ray (AP View) Pre op X-ray (Lateral)

Post op x-ray Post op x-ray

~ 321 ~

International Journal of Orthopaedics Sciences

3 months follow up 3 months follow up

6 months follow up 6 months follow up

Fig 3: Clinical follow up range of motion photograph

Discussion

The femoral neck fracture is the most common skeletal injury,

occurring with minor trauma in the osteoporotic bone of

elderly patients. In younger patients, usually with a high

energy trauma.

The management of this fracture has evolved significantly

Closed reduction and immobilization in POP hip spica in

abduction and internal rotation (Whitman abduction

plaster) in the early part of 20th century [9, 10]. High

incidence of non-union, AVN, bedsores and respiratory

complications led to exploration of methods of internal

fixation.

The introduction of SP Nail brought a new aspiration of

solving the problem, but high failure and complication

rates disappointed many surgeons.

Further improvement in implant designs brought a newer

designs like SP nail plate and McLaughlin nail plate

which did not the withstand the test of time.

The modern concepts of fixation under compression led

to the use of partially threaded cancellous screws and

placement over preliminary wires led to the development

of cannulated variety of screws, which are now the

standard of care in adults. Smooth pins (Moore or

Knowles pins) are still the choice for children.

The presentation at different ages possess different problems

related to the management. The issues are fixation failure in

osteopenic bone of the elderly, marked displacement of

fragments, posterior comminution and disruption of blood

supply in young adults and a higher incidence of AVN and

non-union young adults.

The blood supply to the femoral head is derived from from

primarily from three sources, medial femoral circumflex

artery and lateral femoral circumflex artery through the

extracapsular arterial ring formed at the base of neck of femur

and subsequently through intracapsular terminal branches

which run parallel to the neck and obturator artery via the

artery of ligamentum teres. A femur neck fracture is

considered a vascular injury to the femoral head as it disrupts

the terminal vessels (the retinacular arteries) which lie in

close conjunction to the femoral neck. It is an intracapsular

fracture which exposes it to synovial fluid which had factors

neovascularization. Moreover due to action of theses

surrounding musculature and fracture pattern a high degree of

sheering strain is subjected to it. Hence, proper anatomical

reduction and secure internal fixation are of paramount

importance in its treatment.

The treatment of fracture neck of femur with anatomical

reduction, early and stable fracture fixation using cannulated

screws has been found to give a high proportion of excellent

and good results [6, 8, 11]. This study supports these conclusions.

Statistic Results of Surgery

Most of the cases (70%) were operated in the first 12

hours.

All the cases were operated under spinal anaesthesia.

On an average the duration of surgery was one hour.

1) Age Distribution: In our study fractures were commoner

(55%) in the 31-50 age group with mean age being 41.3

years. The findings in our stuidy are comparable to those

in a study by Christopher Koo Chee Han et al. [40].

~ 322 ~

International Journal of Orthopaedics Sciences Table 10: Age distribution comparison

Study No. of cases Mean age

(in years)

Vijay V et al. [12] 25 50 (20-90)

Dincel Y M et al. [13] 67 46.5 (18-75)

Christopher Koo Chee Han et al. [11] 53 42.1 (6-91)

Present study 30 41.3 (24-65)

2) Sex Distribution: Our series had a male predominance

with 70% and male: female ratio of 2.33:1. The findings

are comparable to the studies by Christopher Koo Chee

Han et al. and Vijay V. The male preponderance in our

series can be accredited to the cause of fracture mainly

being RTA.

Table 11: Sex distribution comparison

Study No. of male:

female

Male:

Female

Vijay V et al. [12] 30:34 2.57:1

Dincel Y M et al. [13] 39:28 1.3:1

Christopher Koo Chee Han et al. [11] 39:14 2.7:1

Present study 21:9 2.33:1

3) Garden’s Type of Fracture: In our study, Garden’s

classification system was used for operative evaluation.

The most common type of injury was type II, 15 cases

(50%) followed by type III, 8 cases (26.66%).

Table 12: Fracture type comparison

Study Garden type

I & II

Garden type

III & IV

Vijay V et al. [12]. 11 14 (56%)

Dincel Y M et al. [13]. 30 (44.7) 37 (55.3)

Christopher Koo Chee Han et al. [11]. 17 (32.1) 36 (67.9)

Present study 18(60) 12 (40)

4) Functional Results: The functional results in our study

were calculated using the Modified Harris Hip Score. The

score was calculated at each follow-up and the functional

result was based on the score at the final follow-up. The

functional results of the present study were comparable

with that of Vijay V et al. with 73.33% excellent results,

20% having good results and fair results in 6.66%.

Table 13: Functional results comparison

Study Excellent

(%)

Good

(%)

Fair

(%)

Poor

(%)

Vijay V [12]. 18 (72) 4 (16) 2 (8) 1 (4)

Christopher Koo Chee Han et al. [11].

41 (93.2) 0 2 (4.5) 1 (2.27)

Present study 22 (73.33) 6 (20) 2 (6.66) 0

5) Union Duration and Rate: In our study, the average

time taken for union was 15weeks. Most of the case

showed union in 12weeks (17 patients). No patient had

non-union. The findings of the present study were

comparable with that of Christopher Koo Chee Han et al.

Table 14: Union duration and rate comparison

Study Weeks No. of

union (%)

Non

union

Vijay V et al. [12]. - 24 (96) 1

Dincel Y M et al. [13]. 24 64 (95.52) 3 (4.47)

Christopher Koo Chee Han et al. [11]. 14.96 52 (98.11) 1 (1.89)

Present study 15 30 (100%) Nil

6) Time Interval Between Injury and Surgery

In our study, most of the cases were operated within the first

12 hours of the trauma, 18 cases (60%).

Table 15: Time elapsed between trauma and surgery comparison

Study <12 hours (%) >12 hours (%)

Vijay V et al. [12] Nil 25 (100)

Dincel Y M et al. [13] 67 (100) Nil

Christopher Koo Chee Han et al. [11] 25 (47.17) 28 (52.83)

Present study 18 (60) 12 (40)

7) Complications: The complications seen were superficial

infection, restricted movements and backing out of

screws. In our study further follow up is necessary to

evaluate the incidence of AVN. All patients were able to

carry out their daily activity with minimal or no

discomfort. 4 (13.33%) patients in our study had screw

back-out and superficial infections.

Preservation of the femoral head with internal fixation is

desirable in younger and more active patients with a femoral

neck fracture. A healed femoral neck fracture, without the

development of osteonecrosis, leads to a good functional

outcome [11]. Eventual good outcomes after fixation are

dependent on:

The factors under surgeon’s control such as quality of

reduction, stable fixation and timing of surgery

Factors not under surgeon’s control such as initial

fracture displacement and disruption of femur head blood

flow and patients presenting late [14].

Swiontkowski [6, 8] stated that early fixation, ideal reduction

the most important factors for successful surgery, and should

be done in 12 h. In our study, most of the fractures (60%)

were fixed within 12 hours and the final results in all but one

case were excellent. The other case had a good result at last

follow up.

Jain et al. [5], in their study compared the functional outcome

of femur neck internal fixation within 12 hours and after 12

hours in patients under 60 years of age over a follow up

period of 2 years and they did not find any significant

difference in the outcome. Our study confirmed the same as

there was no difference in the outcome of patients operated

early (<12 hours) and late (>12 hours). Functional results are

similar in both groups.

Placement of the screw is also of paramount importance.

Inverted triangle with apex inferior is preferred as there will

be less stress raiser affect and decreases the subsequent

chances of subtrochanteric fracture. The screws should be

placed as far as possible from one another close to the cortical

bone of femoral neck. Screws should be parallel with

unacceptation of not more than 10 degree angulation between

them. Screws tips should be within 5mm of subchondral bone [15].

In our study early non-weight bearing ambulation was

allowed with the help of a walker strictly for 8 weeks. Partial

weight bearing was allowed following 8 weeks and full

weight bearing was allowed once radiological signs of union

were seen. The normal hip range of motion was restored in

almost all cases.

The superior rate of fracture healing in the study was

attributed to the good bone quality and healing potential of the

femoral head and neck of most young patients and due to

early fracture fixation.

The limitations of our study include small size of the study

group, short follow up which was not enough to evaluate and

~ 323 ~

International Journal of Orthopaedics Sciences comment on the incidence of AVN. The study require further

follow up to comment on incidence of AVN.

The treatment of fracture neck of femur in adults with

anatomical closed reduction stable internal fixation using

cannulated cancellous screw was found to give a satisfactory

proportion of excellent and good results 6,8,11. This study

supports these conclusions and the results were comparable

with those in the other studies.

Conclusion

In the study, 30 cases of fracture neck of femur were treated

surgically by closed reduction and internal fixation with

cannulated cancellous screws. In conclusion, fracture neck of

femur in young adults treated surgically by closed reduction

and fixation with cannulated cancellous screw fixation gave

excellent to good functional outcome in 93.33%. Hence this

would be the best procedure for management of fracture neck

of femur in adults under 65 years of age even for displaced

fractures and the review of data and our study all point to the

fixation of fracture as early as possible to avoid poor results.

References 1. Keating JF. Femoral neck fractures. In: Court-Brown

CM, Heckman JD, McQueen MM, Ricci WM, Tornetta

III P. Rockwood and Green’s Fractures in adults 8th ed.

Philadelphia: Lippincott Williams & Wilkins, 2015,

2031-73.

2. Weinlein JC. Fractures and dislocations of the hip. In:

Azar FM, Beaty JH, Canale ST. Campbell’s operative

orthopedics 13th ed. Philadelphia: Mosby Elsevier, 2018,

2817-57.

3. Lee KBL, Howe TS, Chang HC. Cancellous screw

fixation for femoral neck fracture: one hundred and

sixteen patients. Ann Acad Med Singapore. 2004;

33:248-51.

4. Rai SK et al. Fracture neck of femur treated with

hemiarthroplasty and cannulated cancellous screw

fixation: a comparative study. Int J Res Orthop. 2017;

3(4):849-53.

5. Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR,

Mahomed NN. Comparison of early and delayed fixation

of subcapital hip fractures in patients sixty years of age or

less. J Bone Joint Surg Am. 2002; 84:1605-12.

6. Thuan VL, Swiontkowski MF. Treatment of Femoral

Neck fractures in Young Adults. J Bone Joint Surg Am.

2008; 90:2254-66.

7. Protzman RR, Burkhalter WE. Femoral neck fractures in

young adults. J Bone joint Surg Am. 1976; 58: 689-95.

8. Swiontkowski MF, Winquist RA, Hansen ST. Fractures

of femoral neck in patients between ages of twelve and

forty nine years. J Bone Joint Surg Am. 1984; 66:837-46.

9. Whitman R. A new method of treatment for fractures of

the neck of the femur, together with remarks on coxa

vara. Ann Surg. 1902; 36(5):746-61.

10. Whitman R. The abduction method considered as the

standard routine in the treatment of fractures of the neck

of femur. Ann Surg. 1920; 81(1):374-91.

11. Khoo CCH, Haseeb A, Singh VA. Cannulated Screw

Fixation For Femoral Neck Fractures: A 5-year

Experience in a Single Institution. Malays Orthop J.

2014; 8(2):14-21.

12. Vijay V, Srivastava N. Cannulated cancellous screws

fixation in intracapsular fracture neck femur: a study with

an emphasis on result of osteosynthesis Int J Res Orthop.

2016; 2(3):181-8.

13. Dinçel YM, Öner A, Arıkan Y, Özkul B, Özcafer R,

Güleç MA. Closed reduction and fixation of high-energy

femoral neck fractures: Still a viable surgical treatment

option. Biomed Res. 2017; 28(20):9028-31.

14. Szita J, Fekete K. Intracapsular femoral neck fractures:

the importance of early reduction and stable

osteosynthesis. Injury. 2002; 33(3):C41-6.

15. Forsh DA, Ferguson TA. Contemporary management of

femoral neck fractures: the young and the old. Curr Rev

Musculoskelet Med. 2012; 5(3):214-21.